Establishing Safe Staffing Establishing Safe Staffing Patterns For NursingPatterns For Nursing
HIMSS Safe Staffing Work GroupHIMSS Safe Staffing Work Group
Co-Chairs:
Susan Newbold, PhD, FHIMSS Professor-
Vanderbilt University [email protected]
Frank Overfelt, MBA, LFHIMSS, President-
Delta Healthcare Consulting Group, [email protected]
Additional Work Group Members•
J Anderson•
Ali Birjandi•
David Butler•
Christopher Daute•
Sherry Davis•
David Eitel, MD•
Robert Gleason, MN, RN•
John Hansmann, MSIE, CPHIMSS, FHIMSS
•
Helen L. Hill, FHIMSS•
Linda Howell, RN
•
Kristie Huff, RN•
Denise Kishel, MBA, MSN, RN•
Pat Lasky, BSN, RN•
Kathleen Malloch, PhD, RN•
Mary Lou Matheke, PhD, RN•
Gia Milo-Slagle•
Andrea Schmid-Mazzoccoli, RN•
Pierce Story•
Mary Lou Weden, RN, MSN•
Kristen Werner
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Presentation Overview
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Discuss background on Safe Staffing
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Options for Nurse Staffing
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Data-driven Nurse Staffing Methodology
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Conclusions
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Data Driven Approach to Nurse Staffing
“Hospitals are held together, glued together, enabled to function…by the nurses”
Thomas, L.1983
“Nurses are the early warning system for early detection of complications and early detection of problems in care…”
Aiken L. et al, 2003
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Patti Rogers & Frank C. Overfelt 2009
Cimiotti, Haas, Saiman, Larson, 2006
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Higher RN HPPD resulted in 79% reduction in risk of blood stream infection between 2 NICUs
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Recommended that staffing decisions based on census be transformed into acuity driven staffing decisions
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Findings suggest that RN staffing associated with risk of bloodstream infection in NICU
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Establishing Safe Staffing Patterns for Nursing
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“Patient Safety and Quality Patient Care can be enhanced through the collaborative efforts of all HIMSS/SHS communities to provide useful and effective information technology, enhanced processes, and appropriately designed staffing ratios for Nursing Staff”HIMSS position paper on Safe Staffing Ratios-
June 2006
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Establishing Safe Staffing Patterns for Nursing
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Background–
Mandatory Staffing Ratios
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States and Federal Government•
Driven primarily by CNA and other nurses’
unions
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Being touted as “safe staffing ratios”, but based upon no documentable evidence.
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Same ratios Days and Nights
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Enacted legislation/adopted regulations to date: (13 states plus DC) CA, CT, DC*, FL, IL, ME*, NJ, NV+, OH, OR, RI, VT, WA, TX[ regulations]
+ represents legislation requiring a study* legislation was either waived or modified from that which was enacted
Introduced in 2008; (13 states); AZ, CT, FL, HI, IA, MN, MO, NJ, NM, NY, OH, VA, and WV.
The American Nurses Association Nationwide State Legislative Agenda
NURSE STAFFING PLANS AND RATIOS
As of Feb 2009 8
Establishing Safe Staffing Patterns for Nursing
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Only California and Massachusetts have actually passed legislation mandating minimal ratios.
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There has been NO evidence that these ratios have resolved any patient safety issues nor improved patient outcomes
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Alternatives to Mandatory Staffing
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HIMSS proposes alternatives to mandatory staffing
*Benchmarking *Benchmarking supplemented by work sampling
*Work sampling only *Detailed data collection
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What Are the Options for Nurse Staffing?
Data Driven Safe Staffing Systems
– Every patient is different by dependency system
– Accounts for recent procedures
– Workload tied to evidence in patient’s chart
– Accounts for various aspects of ADL
Fixed Ratios
– Every patient is the same– Arbitrarily set, even
legislated– All units with the same
designation are the same
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What Are the Options for Nurse Staffing?
Data Driven Safe Staffing Systems
– Layout & design issues considered
– Ancillary Department support built in
– Family interaction with the patient is factored in
– Accounts for LOS
Fixed Ratios
– All hospitals are the same– Requires some nurses to
work harder and longer than some others
– Nurse has an imbalanced workload even if she has the same number of patients
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Ratios Don’t Equal Hours
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What Are the Options for Nurse Staffing?
Data Driven Safe Staffing Systems
– Accounts for technological support (EMR, electronic med cabinets, etc)
– Bed turnover issues
Fixed Ratios
– All shifts are staffed the same
– Technology is ignored– Unique patient turnover is
ignored
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Patient Classification Tool Sets (One size does not fit all)
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Evidence-based Staffing Systems must be customized for all Nursing Specialties:
• Women’s Health • L&D• NICU/Nursery • PICU/Pediatrics• Oncology• Palliative Care•
Emergency
Department
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Engineered Safe Staffing for Nursing•
Evidence-based or engineered Safe Staffing Systems for Nursing include two major components:
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Patient Classification (Acuity/Dependency) Systems, which groups patients into similar groups
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Development of Engineered Staffing Ratios, also called workload measurement to establish a foundational database
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The two must be linked
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Patti Rogers & Frank C. Overfelt 2009
Essential Elements of a Valid Dependency Staffing/Classification System
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Objective –
Not subject to individual interpretation (high inter-rater reliability)
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Auditable –
Traced back to patient chart/orders•
Discriminating –
Criteria sets must differentiate
between various patients•
Statistically valid- Using generally acceptable statistical validation methodologies
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Workload Measurement What is it?
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Workload measurement is the process of determining the hours of care required by each patient in each “bucket”
or dependency level
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Multiple options for developing engineered staffing ratios:─
Use of hospital’s budgeted HPPD─
Work sampling ─
Use of database of treatment profiles─
Detailed engineered staffing ratios/treatment profile development
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It accounts for the:─Specific layout and design features of a facility─Technological support (EMR or not; CPOE or
not, etc.)─Unique dependency/acuity requirements of the
patient
AONE Requirements for Setting Engineered Staffing Ratios
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It accounts for the (cont’d):
─Ancillary department support (pharmacy, imaging, transport, EVS, etc.)
─Specific mission of the hospital (teaching or not; specialty of the hospital (pediatric, cardiac, cancer, etc.))
─Skill mix and education level of the nursing staff
AONE Requirements for Setting Engineered Staffing Ratios
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Benchmarking Services
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NACHRI (for Pediatrics)•
NDNQI
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CALNOC https://www.calnoc.org/globalPages/mainpage.aspx
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Solucient www.thomsonreuters.com•
GHC Consulting [[email protected]]
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Delta Healthcare Consulting Group www.deltahcg.com
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Workload Measurement Work Sampling
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3rd
Party Observer
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Observations every 10-15 minutes•
Focus on Staff, not patient
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Provides work distribution by skill, by shift•
24 hour sampling time/unit
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Workload Measurement Work Sampling
•During Work Sampling Process issues can be identified•Stage bed huddles in the Emergency Department so the LOS of ED patients can be observed first hand •Take action to prevent bolus of admissions occurring at change of shift (from the ED).
-Staffing on inpatient units is already set (2 hours in advance of shift)
-Transportation of patients to unit at last minute may cause overtime and delays
-Nurses on inpatient units are not available for receiving reports on inbound patients.
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Workload Measurement Detailed Standards Development
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The hours of care by acuity level are found by measuring four types of activities:
─Direct care activities (documented)─Direct care activities (undocumented)─Indirect care activities─Routine activities
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Sample Results of Detailed Engineered Staffing Ratios
– Where Nurses spend
their time:
Direct Care - Undocument
25%
Indirect6%
Direct Care - Documented
51%
Routine18%
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Goals & Objectives of Safe Engineered Staffing
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Optimize staffing at the unit level
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Allocation of appropriate activities to appropriate skill levels
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Balance Patient Assignments among Caregivers
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Maximize efficiency (minimize non-value added activities)
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Patient Classification Services
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McKesson www.mckesson.com/en_us/McKesson.com/For%2BHealthcare%2BProvid
ers/Hospitals/Nursing%2BSolutions/ANSOS%2BOne-Staff.html
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Delta Healthcare Consulting Groupwww.deltahcg.com
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Optilink www.advisoryboardcompany.com/content/optilink/optilink.html
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ResQwww.res-q.com
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Clairvia•
API Healthcare
http://www.apihealthcare.com/products/patient_classification/
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Patient Classification + Workload Measurement The Result
Aligns with accrediting & regulatory guidelines for staffing:
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ANCC Magnet Accreditation –
AONE
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JCAHO–
State Boards of Nurse Examiners recommendations for staffing
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Summary
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The patient must remain the focus!•
Improved patient care outcomes is a shared goal
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Optimal nurse staffing can improve patient outcomes•
Call to action: Creation of staffing models qualified through the metrics of engineered staffing systems to provide the most effective match between available resources and desired patient outcomes.
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